Pancreatic pseudocyst... - Forum

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Pancreatic pseudocyst... - Ärzteforum

Post#1 »

Have a male patient, 53 y.o. with a biliary acute pancreatitis that started about one and a half month ago,relatively mild in its clinical manifestations,when USN was done,showed a gallbladder full with stones, a normal CBD and a notorious enlargment of the pancreas...LFT within normal ranges,high levels of amylase and days later,a CT scan was performed and showed important diffuse enlargment of the whole pancreas with a huge cyst growing near the body and tail that rejected forwardly the stomach.

We made the diagnosis of a pseudocyst and waited for about one month before checking again with CT scan that showed that the cyst had grew reaching some 8 x 9 cms in diameter.

Two weeks ago, through endoscopy, a transgastric punction was done and a 7F catheter installed into the cavity...Some 700 mls. of a pinky fluid was aspirated...Since then,the cath has continue to drain about 180 - 200 cc of the same fluid, rich in amylases,around 33.000 U...New CT scan shows reduction of the cavity in some 40 % of its previous volume...The pt has continue to present fever, leucocitosis but no septic condition...He is under enteral nutrition through a naso yeyunal tube advanced quite distal to the angle of Treitz.

We are expecting to do an ERCP to see if there's a wide communication with pancreatic ducts...Depending on that,do you think surgical approach should be consider?.

Any comments or suggestions?


Re: Pancreatic pseudocyst... - Ärzteforum

Post#2 »

The $64 dollar question is whether your catheter is efficiently draining the pseudocyst. If it isn't,.... a marsupialization into the back wall of the stomach breaking down any loculations as only your finger can do. Unless there is a segregated collection in another part of the pancreas, I think ERCP will only be used as the drunkard uses the lampost, for support rather than illumination. If there should be proximal ductal obstruction, good distal drainage into the stomach, or a loop of jejunum for that matter, should take care of it....Regards from a sweltering summer in southwestern Ontario Canada, percolating my Celtic blood.


Re: Pancreatic pseudocyst... - Ärzteforum

Post#3 »

Sorry, but one would of course be doing this at the time of open cholecystectomy and CBD clearance. Maybe trying to do this endoscopically/laparoscopically is grandstanding a bit too much at this point...? So this guy can get out of hospital a few days earlier?? It sounds like he's already been through the bloody mill already. But let's hear from the others.

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Re: Pancreatic pseudocyst... - Ärzteforum

Post#4 »

I'm not sure I understand what you have done. When I
have done this, the endoscopic transgastric puncture has resulted in a
massive rush of fluid and prompt collapse of the cyst (only 2
cases). I didn't put in any catheter. If you have a catheter
one meter long going into the cyst and out the nose or wherever, I
suspect that the resistance of the catheter is preventing adequate
drainage. Or perhaps I don't understand what you have done.

There are numerous reports of intragastric endoscopic surgery; put a
trocar into the stomach and insert a laparoscope. Put in the
gastroscope or another port and open further the communication with the
pseudocyst... you get the idea.

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Lady Surgeon

Re: Pancreatic pseudocyst... - Ärzteforum

Post#5 »

I think some endoscopists are burning a wide communication between the
pancreatic pseudocyst and the stomach using either the colonoscopic hot
biopsy forceps or the polypectomy snare or perhaps the gastroscopic
heater probe or similar endoscopic cautery devices. You already have
found a good location--if you could just make a bigger hole
endoscopically this would be easiest.


Re: Pancreatic pseudocyst... - Ärzteforum

Post#6 »

your pseudocyst is inadequately drained, it should
be mature by now so do an open posterior cyst gastrostomy and while you are
in there whip out the GB. If it looks dangerous then do a subtotal
cholecystectomy taking care to remove all stones.

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